International cross-cultural development and field testing of the primary care practice questionnaire for the PaRIS survey (PaRIS-PCPQ).

BACKGROUND: The PaRIS survey, an initiative of the Organisation for Economic Co-operation and Development (OECD), aims to assess health systems performance in delivering primary care by measuring the care experiences and outcomes of people over 45 who used primary care services in the past six months. In addition, linked data from primary care practices are collected to analyse how the organisation of primary care practices and their care processes impact care experiences and outcomes. This article describes the development and validation of the primary care practice questionnaire for the PaRIS survey, the PaRIS-PCPQ. METHOD: The PaRIS-PCPQ was developed based on domains of primary care practice and professional characteristics included in the PaRIS conceptual framework. Questionnaire development was conducted in four phases: (1) a multi-step consensus-based development of the source questionnaire, (2) translation of the English source questionnaire into 17 languages, (3) cross-national cognitive testing with primary care professionals in participating countries, and (4) cross-national field-testing. RESULTS: 70 items were selected from 7 existing questionnaires on primary care characteristics, of which 49 were included in a first draft. Feedback from stakeholders resulted in a modified 34-item version (practice profile, care coordination, chronic care management, patient follow-up, and respondent characteristics) designed to be completed online by medical or non-medical staff working in a primary care practice. Cognitive testing led to changes in the source questionnaire as well as to country specific localisations. The resulting 32-item questionnaire was piloted in an online survey and field test. Data from 540 primary care practices from 17 countries were collected and analysed. Final revision resulted in a 34-item questionnaire. CONCLUSIONS: The cross-national development of a primary care practice questionnaire is challenging due to the differences in care delivery systems. Rigorous translation and cognitive testing as well as stakeholder engagement helped to overcome most challenges. The PaRIS-PCPQ will be used to assess how key characteristics of primary care practices relate to the care experiences and outcomes of people living with chronic conditions. As such, policymakers and care providers will be informed about the performance of primary care from the patient's perspective.

Primary care and multimorbidity in six Latin American and Caribbean countries.

OBJECTIVES: To describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments. METHODS: Cross-sectional data are from the Inter-American Development Bank's international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care. RESULTS: The prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one's conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams. CONCLUSIONS: Multimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

Primary care and multimorbidity in six Latin American and Caribbean countries

[ABSTRACT]. Objectives. To describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments. Methods. Cross-sectional data are from the Inter-American Development Bank’s international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care. Results. The prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one’s conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams. Conclusions. Multimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

[RESUMEN]. Objetivos. Describir los modelos de multimorbilidad en seis países distintos de América Latina y el Caribe, examinar sus efectos en las experiencias de atención primaria y evaluar su influencia con base en informes sobre evaluaciones generales de atención de salud. Métodos. Los datos transversales son de la encuesta internacional de atención primaria del Banco Interamericano de Desarrollo, realizada en el 2013-2014, y representan la población adulta de Brasil, Colombia, El Salvador, Jamaica, México y Panamá. Se utilizaron modelos robustos de regresión de Poisson en personas con multimorbilidad para estimar hasta qué punto reciben la atención primaria suficiente y apropiada, tienen confianza en que pueden controlar su estado de salud, y pueden costear la atención médica necesaria. Resultados. Se observó que la prevalencia de la multimorbilidad abarcaba desde 17,5% en Colombia hasta 37,3% en Jamaica. La mayoría de las afecciones examinadas se presentan acompañadas de otras, siendo la diabetes y las cardiopatías los dos problemas más asociados con otras afecciones. La proporción de adultos que afrontan pagos directos altos, problemas para pagar sus cuentas médicas, consultas con múltiples médicos y un estado de salud entre aceptable y desmejorado fue mayor en aquellos con niveles de multimorbilidad más altos y experiencias de atención primaria más deficientes. La multimorbilidad y las dificultades concernientes a la atención primaria presentaron una asociación positiva con la dificultad para costear la atención médica y controlar su estado de salud. No obstante, los adultos con multimorbilidad tenían mayores probabilidades de haber recibido asesoramiento sobre su estilo de vida y de estar al día con sus exámenes preventivos. Conclusiones. La multimorbilidad se notifica con frecuencia. Ofrecer un cuidado adecuado para el número cada vez mayor de pacientes con esas características es un reto importante al que se enfrenta la mayoría de los sistemas de salud, que necesitarán un fortalecimiento considerable de la atención primaria y de la protección financiera para atender a aquellos más necesitados.

[RESUMO]. Objetivos. Descrever os padrões de multimorbidade em seis países da América Latina e Caribe, examinar os efeitos da multimorbidade na prática de atenção primária e avaliar a influência nas avaliações relatadas pelos pacientes atendidos. Métodos. Estudo baseado em dados transversais obtidos de uma pesquisa internacional de atenção primária realizada pelo Banco Interamericano de Desenvolvimento (BID) em 2013–2014, representativos da população adulta do Brasil, Colômbia, El Salvador, Jamaica, México e Panamá. Modelos robustos de regressão de Poisson foram usados para estimar em que medida a atenção primária prestada aos pacientes com multimorbidade é adequada e oportuna, eles se sentem seguros em controlar a própria doença e podem pagar pela atenção médica necessária. Resultados. A prevalência de multimorbidade variou entre 17,5% na Colômbia e 37,3% na Jamaica. A maioria das doenças avaliadas ocorre junto com outros problemas, sendo a diabetes e a doença cardíaca mais comumente associadas a outras doenças. Os percentuais de adultos que relataram grandes desembolsos por conta própria, dificuldade para pagar as contas médicas, consultas a vários médicos distintos e estado de saúde regular/ruim foram maiores nos pacientes com maior número de doenças e experiências de atendimento piores na atenção primária. A multimorbidade e problemas com a atenção primária tiveram uma associação positiva com a dificuldade de pagar pela atenção médica e controlar a própria doença. Porém, verificou-se uma probabilidade maior de os adultos com multimorbidade receberem orientações sobre estilo de vida e manter em dia os exames preventivos. Conclusões. A multimorbidade é frequente. Proporcionar atenção adequada ao número crescente de pacientes portadores de diversas doenças é um grande desafio enfrentado pela maioria dos sistemas de saúde e requer um reforço substancial da atenção primária e proteção financeira para os mais carentes.

Primary care and multimorbidity in six Latin American and Caribbean countries / Atención primaria y multimorbilidad en seis países de América Latina y el Caribe / Atenção primária e multimorbidade em seis países da América Latina e Caribe

ABSTRACT Objectives To describe patterns of multimorbidity in six diverse Latin American and Caribbean countries, examine its effects on primary care experiences, and assess its influence on reported overall health care assessments. Methods Cross-sectional data are from the Inter-American Development Bank's international primary care survey, conducted in 2013/2014, and represent the adult populations of Brazil, Colombia, El Salvador, Jamaica, Mexico and Panama. Robust Poisson regression models were used to estimate the extent to which those with multimorbidity receive adequate and appropriate primary care, have confidence in managing their health condition, and are able to afford needed medical care. Results The prevalence of multimorbidity ranged from 17.5% in Colombia to 37.3% in Jamaica. Most of the examined conditions occur along with others, with diabetes and heart disease being the two problems most associated with other conditions. The proportions of adults with high out-of-pocket payments, problems paying their medical bills, seeing multiple doctors, and being in only fair/poor health were higher among those with greater levels of multimorbidity and poorer primary care experiences. Multimorbidity and difficulties with primary care were positively associated with trouble paying for medical care and managing one's conditions. Nonetheless, adults with multimorbidity were more likely to have received lifestyle advice and to be up to date with preventive exams. Conclusions Multimorbidity is reported frequently. Providing adequate care for the growing number of such patients is a major challenge facing most health systems, which will require considerable strengthening of primary care along with financial protection for those most in need.

RESUMEN Objetivos Describir los modelos de multimorbilidad en seis países distintos de América Latina y el Caribe, examinar sus efectos en las experiencias de atención primaria y evaluar su influencia con base en informes sobre evaluaciones generales de atención de salud. Métodos Los datos transversales son de la encuesta internacional de atención primaria del Banco Interamericano de Desarrollo, realizada en el 2013-2014, y representan la población adulta de Brasil, Colombia, El Salvador, Jamaica, México y Panamá. Se utilizaron modelos robustos de regresión de Poisson en personas con multimorbilidad para estimar hasta qué punto reciben la atención primaria suficiente y apropiada, tienen confianza en que pueden controlar su estado de salud, y pueden costear la atención médica necesaria. Resultados Se observó que la prevalencia de la multimorbilidad abarcaba desde 17,5% en Colombia hasta 37,3% en Jamaica. La mayoría de las afecciones examinadas se presentan acompañadas de otras, siendo la diabetes y las cardiopatías los dos problemas más asociados con otras afecciones. La proporción de adultos que afrontan pagos directos altos, problemas para pagar sus cuentas médicas, consultas con múltiples médicos y un estado de salud entre aceptable y desmejorado fue mayor en aquellos con niveles de multimorbilidad más altos y experiencias de atención primaria más deficientes. La multimorbilidad y las dificultades concernientes a la atención primaria presentaron una asociación positiva con la dificultad para costear la atención médica y controlar su estado de salud. No obstante, los adultos con multimorbilidad tenían mayores probabilidades de haber recibido asesoramiento sobre su estilo de vida y de estar al día con sus exámenes preventivos. Conclusiones La multimorbilidad se notifica con frecuencia. Ofrecer un cuidado adecuado para el número cada vez mayor de pacientes con esas características es un reto importante al que se enfrenta la mayoría de los sistemas de salud, que necesitarán un fortalecimiento considerable de la atención primaria y de la protección financiera para atender a aquellos más necesitados.

RESUMO Objetivos Descrever os padrões de multimorbidade em seis países da América Latina e Caribe, examinar os efeitos da multimorbidade na prática de atenção primária e avaliar a influência nas avaliações relatadas pelos pacientes atendidos. Métodos Estudo baseado em dados transversais obtidos de uma pesquisa internacional de atenção primária realizada pelo Banco Interamericano de Desenvolvimento (BID) em 2013-2014, representativos da população adulta do Brasil, Colômbia, El Salvador, Jamaica, México e Panamá. Modelos robustos de regressão de Poisson foram usados para estimar em que medida a atenção primária prestada aos pacientes com multimorbidade é adequada e oportuna, eles se sentem seguros em controlar a própria doença e podem pagar pela atenção médica necessária. Resultados A prevalência de multimorbidade variou entre 17,5% na Colômbia e 37,3% na Jamaica. A maioria das doenças avaliadas ocorre junto com outros problemas, sendo a diabetes e a doença cardíaca mais comumente associadas a outras doenças. Os percentuais de adultos que relataram grandes desembolsos por conta própria, dificuldade para pagar as contas médicas, consultas a vários médicos distintos e estado de saúde regular/ruim foram maiores nos pacientes com maior número de doenças e experiências de atendimento piores na atenção primária. A multimorbidade e problemas com a atenção primária tiveram uma associação positiva com a dificuldade de pagar pela atenção médica e controlar a própria doença. Porém, verificou-se uma probabilidade maior de os adultos com multimorbidade receberem orientações sobre estilo de vida e manter em dia os exames preventivos. Conclusões A multimorbidade é frequente. Proporcionar atenção adequada ao número crescente de pacientes portadores de diversas doenças é um grande desafio enfrentado pela maioria dos sistemas de saúde e requer um reforço substancial da atenção primária e proteção financeira para os mais carentes.

Assessment of quality of primary care with facility surveys: a descriptive analysis in ten low-income and middle-income countries.

BACKGROUND: Primary care has the potential to address a large proportion of people's health needs, promote equity, and contain costs, but only if it provides high-quality health services that people want to use. 40 years after the Declaration of Alma-Ata, little is known about the quality of primary care in low-income and middle-income countries. We assessed whether existing facility surveys capture relevant aspects of primary care performance and summarised the quality of primary care in ten low-income and middle-income countries. METHODS: We used Service Provision Assessment surveys, the most comprehensive nationally representative surveys of health systems, to select indicators corresponding to three of the process quality domains (competent systems, evidence-based care, and user experience) identified by the Lancet Global Health Commission on High Quality Health Systems in the Sustainable Development Goals Era. We calculated composite and domain quality scores for first-level primary care facilities across and within ten countries with available facility assessment data (Ethiopia, Haiti, Kenya, Malawi, Namibia, Nepal, Rwanda, Senegal, Tanzania, and Uganda). FINDINGS: Data were available for 7049 facilities and 63 869 care visits. There were gaps in measurement of important outcomes such as user experience, health outcomes, and confidence, and processes such as timely action, choice of provider, affordability, ease of use, dignity, privacy, non-discrimination, autonomy, and confidentiality. No information about care competence was available outside maternal and child health. Overall, scores for primary care quality were low (mean 0·41 on a scale of 0 to 1). At a domain level, scores were lowest for user experience, followed by evidence-based care, and then competent systems. At the subdomain level, scores for patient focus, prevention and detection, technical quality of sick-child care, and population-health management were lower than those for other subdomains. INTERPRETATION: Facility surveys do not capture key elements of primary care quality. The available measures suggest major gaps in primary care quality. If not addressed, these gaps will limit the contribution of primary care to reaching the ambitious Sustainable Development Goals. FUNDING: Bill & Melinda Gates Foundation.

Patient-centered primary care and self-rated health in 6 Latin American and Caribbean countries: Analysis of a public opinion cross-sectional survey.

BACKGROUND: Despite the substantial attention to primary care (PC), few studies have addressed the relationship between patients' experience with PC and their health status in low-and middle-income countries. This study aimed to (1) test the association between overall patient-centered PC experience (OPCE) and self-rated health (SRH) and (2) identify specific features of patient-centered PC associated with better SRH (i.e., excellent or very good SRH) in 6 Latin American and Caribbean countries. METHODS AND FINDINGS: We conducted a secondary analysis of a 2013 public opinion cross-sectional survey on perceptions and experiences with healthcare systems in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama; the data were nationally representative for urban populations. We analyzed 9 features of patient-centered PC. We calculated OPCE score as the arithmetic mean of the PC features. OPCE score ranged from 0 to 1, where 0 meant that the participant did not have any of the 9 patient-centered PC experiences, while 1 meant that he/she reported having all these experiences. After testing for interaction on the additive scale, we analyzed countries pooled for aim 1, with an interaction term for Mexico, and each country separately for aim 2. We used multiple Poisson regression models double-weighted by survey and inverse probability weights to deal with the survey design and missing data. The study included 6,100 participants. The percentage of participants with excellent or very good SRH ranged from 29.5% in Mexico to 52.4% in Jamaica. OPCE was associated with reporting excellent or very good SRH in all countries: adjusting for socio-demographic and health covariates, patients with an OPCE score of 1 in Brazil, Colombia, El Salvador, Jamaica, and Panama were more likely to report excellent or very good SRH than those with a score of 0 (adjusted prevalence ratio [aPR] 1.61, 95% CI 1.37-1.90, p < 0.001); in Mexico, this association was even stronger (aPR 4.27, 95% CI 2.34-7.81, p < 0.001). The specific features of patient-centered PC associated with better SRH differed by country. The perception that PC providers solve most health problems was associated with excellent or very good SRH in Colombia (aPR 1.38, 95% CI 1.01-1.91, p = 0.046) and Jamaica (aPR 1.21, 95% CI 1.02-1.43, p = 0.030). Having a provider who knows relevant medical history was positively associated with better SRH in Mexico (aPR 1.47, 95% CI 1.03-2.12, p = 0.036) but was negatively associated with better SRH in Brazil (aPR 0.71, 95% CI 0.56-0.89, p = 0.003). Finally, easy contact with PC facility (Mexico: aPR 1.35, 95% CI 1.04-1.74, p = 0.023), coordination of care (Mexico: aPR 1.53, 95% CI 1.19-1.98, p = 0.001), and opportunity to ask questions (Brazil: aPR 1.42, 95% CI 1.11-1.83, p = 0.006) were each associated with better SRH. The main study limitation consists in the analysis being of cross-sectional data, which does not allow making causal inferences or identifying the direction of the association between the variables. CONCLUSIONS: Overall, a higher OPCE score was associated with better SRH in these 6 Latin American and Caribbean countries; associations between specific characteristics of patient-centered PC and SRH differed by country. The findings underscore the importance of high-quality, patient-centered PC as a path to improved population health.

An examination of socioeconomic equity in health experiences in six Latin American and Caribbean countries

[ABSTRACT]. Objective. Most Latin American and Caribbean (LAC) countries are working toward the provision of universal health coverage, and ensuring equity is a priority for those nations. The goal of this study was to examine the extent to which adults’ socioeconomic status was related to health care experience in six LAC countries. Methods. This cross-sectional study examined the relationship between educational attainment and seven health experience outcomes in three areas: assessment of the health system, access to care, and experience with general practitioner. For this work, we used data from an Inter-American Development Bank survey of adults in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama that was conducted in 2012-2014. Results. Brazil and Jamaica, the two countries with unified public coverage, stood out for having substantially greater inequality, according to the results of bivariate analyses, with more-educated respondents reporting better health care experiences for five of the seven outcomes. For Jamaica, educational differences largely remained in multivariate analyses: college graduates were less likely (odds ratio (OR) = 0.37) than those with primary education to report their health system needs major reform and were more likely (OR = 2.57) to have a regular doctor. In Brazil, educational differences were mostly eliminated in multivariate models, though people with private insurance consistently reported better outcomes than those with public coverage. Colombia, in contrast, exhibited the least inequality despite having the highest income inequality of the six countries. Conclusions. Future research is needed to understand the policies and strategies that have resulted in Colombia achieving high levels of equity in patient health care experience, and Jamaica and Brazil demonstrating high levels of inequality.

[RESUMEN]. Objetivo. La mayor parte de los países de América Latina y el Caribe está trabajando para lograr la cobertura universal de salud, por lo que asegurar la equidad es una prioridad para esas naciones. La meta de este estudio fue examinar en qué medida la situación socioeconómica de los adultos se relacionaba con la experiencia de atención de salud en seis países de América Latina y el Caribe. Métodos. En este estudio transversal se examinó la relación entre el nivel educativo alcanzado y siete resultados en cuanto a la experiencia de salud en tres áreas: la evaluación del sistema de salud, el acceso a la atención y la experiencia con un médico general. En este trabajo, se usaron datos de una encuesta del Banco Interamericano de Desarrollo a adultos en Brasil, Colombia, El Salvador, Jamaica, México y Panamá, que se realizó entre el 2012 y el 2014. Resultados. Brasil y Jamaica, dos países con cobertura pública unificada, se destacaron por tener una desigualdad notablemente mayor, según los resultados de los análisis bivariantes, en los que los entrevistados con mayor instrucción informaron mejores experiencias de atención de salud para cinco de los siete resultados. En el caso de Jamaica, las diferencias educativas permanecieron en gran medida después de los análisis multivariantes: los graduados universitarios (razón de posibilidades [OR] = 0,37) eran menos propensos, en comparación con quienes tenían educación primaria, a manifestar la reforma importante que necesita su sistema de salud y eran más propensos (O = 2,57) a tener a un médico de cabecera. En Brasil, si bien las diferencias educativas se eliminaron en gran parte en los modelos con múltiples variables, las personas con cobertura privada manifestaron constantemente mejores resultados que aquellos con cobertura pública. En cambio, Colombia presentó la menor desigualdad a pesar de tener la desigualdad de ingresos más alta de los seis países. Conclusiones. Se precisan investigaciones futuras para comprender las políticas y las estrategias que han llevado a que Colombia alcance niveles altos de equidad en la experiencia de atención de salud de pacientes, y a que Jamaica y Brasil presenten niveles altos de desigualdad.

[RESUMO]. Objetivo. Na América Latina e no Caribe, os países estão trabalhando para alcançar a cobertura universal de saúde e uma das prioridades é assegurar a equidade nestas nações. O objetivo deste estudo foi examinar a relação entre a situação socioeconômica e a experiência em atenção de saúde de adultos em seis países da ALC. Métodos. Foi realizado um estudo transversal para examinar a relação entre aproveitamento escolar e sete desfechos da experiência em saúde em três áreas distintas: avaliação do sistema de saúde, acesso à assistência e experiência com o clínico geral. Foram usados dados de uma pesquisa do Banco Interamericano de Desenvolvimento realizada com adultos no Brasil, Colômbia, El Salvador, Jamaica, México e Panamá em 2012–2014. Resultados. O Brasil e a Jamaica, os dois países com um sistema único de cobertura da rede pública de saúde, se destacaram por ter consideravelmente maior desigualdade segundo os resultados das análises bivariadas, sendo que os participantes com maior nível de instrução informaram experiências melhores em atenção de saúde em cinco dos sete desfechos. Na Jamaica, as diferenças relativas ao nível educacional permaneceram em grande parte nas análises multivariadas: em comparação aos indivíduos com nível primário de educação, os adultos com nível universitário (odds ratio [OR] 0,37) apontaram com menor frequência a necessidade de uma ampla reforma no sistema de saúde e indicaram com maior frequência (OR 2,57) ter um médico habitual. No Brasil, as diferenças relativas ao nível educacional foram na sua maior parte eliminadas nos modelos multivariados, apesar de os indivíduos com plano de saúde privado terem consistentemente informado melhores desfechos que os indivíduos atendidos na rede pública. Em contraste, o menor grau de desigualdade foi observado na Colômbia apesar de o país ter a maior desigualdade de renda dos seis países estudados. Conclusões. Osutras pesquisas são necessárias para compreender as políticas e as estratégias responsáveis pelo alto grau de equidade na experiência em atenção de saúde dos pacientes na Colômbia e pelos altos níveis de desigualdade na Jamaica e no Brasil.

An examination of socioeconomic equity in health experiences in six Latin American and Caribbean countries.

OBJECTIVE: Most Latin American and Caribbean (LAC) countries are working toward the provision of universal health coverage, and ensuring equity is a priority for those nations. The goal of this study was to examine the extent to which adults' socioeconomic status was related to health care experience in six LAC countries. METHODS: This cross-sectional study examined the relationship between educational attainment and seven health experience outcomes in three areas: assessment of the health system, access to care, and experience with general practitioner. For this work, we used data from an Inter-American Development Bank survey of adults in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama that was conducted in 2012-2014. RESULTS: Brazil and Jamaica, the two countries with unified public coverage, stood out for having substantially greater inequality, according to the results of bivariate analyses, with more-educated respondents reporting better health care experiences for five of the seven outcomes. For Jamaica, educational differences largely remained in multivariate analyses: college graduates were less likely (odds ratio (OR) = 0.37) than those with primary education to report their health system needs major reform and were more likely (OR = 2.57) to have a regular doctor. In Brazil, educational differences were mostly eliminated in multivariate models, though people with private insurance consistently reported better outcomes than those with public coverage. Colombia, in contrast, exhibited the least inequality despite having the highest income inequality of the six countries. CONCLUSIONS: Future research is needed to understand the policies and strategies that have resulted in Colombia achieving high levels of equity in patient health care experience, and Jamaica and Brazil demonstrating high levels of inequality.

An examination of socioeconomic equity in health experiences in six Latin American and Caribbean countries / Examen de la equidad socioeconómica en cuanto a las experiencias de salud en seis países de América Latina y el Caribe / Uma análise da equidade socioeconômica em experiências em saúde em seis países da América Latina e do Caribe

ABSTRACT Objective Most Latin American and Caribbean (LAC) countries are working toward the provision of universal health coverage, and ensuring equity is a priority for those nations. The goal of this study was to examine the extent to which adults' socioeconomic status was related to health care experience in six LAC countries. Methods This cross-sectional study examined the relationship between educational attainment and seven health experience outcomes in three areas: assessment of the health system, access to care, and experience with general practitioner. For this work, we used data from an Inter-American Development Bank survey of adults in Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama that was conducted in 2012-2014. Results Brazil and Jamaica, the two countries with unified public coverage, stood out for having substantially greater inequality, according to the results of bivariate analyses, with more-educated respondents reporting better health care experiences for five of the seven outcomes. For Jamaica, educational differences largely remained in multivariate analyses: college graduates were less likely (odds ratio (OR) = 0.37) than those with primary education to report their health system needs major reform and were more likely (OR = 2.57) to have a regular doctor. In Brazil, educational differences were mostly eliminated in multivariate models, though people with private insurance consistently reported better outcomes than those with public coverage. Colombia, in contrast, exhibited the least inequality despite having the highest income inequality of the six countries. Conclusions Future research is needed to understand the policies and strategies that have resulted in Colombia achieving high levels of equity in patient health care experience, and Jamaica and Brazil demonstrating high levels of inequality.

RESUMEN Objetivo La mayor parte de los países de América Latina y el Caribe está trabajando para lograr la cobertura universal de salud, por lo que asegurar la equidad es una prioridad para esas naciones. La meta de este estudio fue examinar en qué medida la situación socioeconómica de los adultos se relacionaba con la experiencia de atención de salud en seis países de América Latina y el Caribe. Métodos En este estudio transversal se examinó la relación entre el nivel educativo alcanzado y siete resultados en cuanto a la experiencia de salud en tres áreas: la evaluación del sistema de salud, el acceso a la atención y la experiencia con un médico general. En este trabajo, se usaron datos de una encuesta del Banco Interamericano de Desarrollo a adultos en Brasil, Colombia, El Salvador, Jamaica, México y Panamá, que se realizó entre el 2012 y el 2014. Resultados Brasil y Jamaica, dos países con cobertura pública unificada, se destacaron por tener una desigualdad notablemente mayor, según los resultados de los análisis bivariantes, en los que los entrevistados con mayor instrucción informaron mejores experiencias de atención de salud para cinco de los siete resultados. En el caso de Jamaica, las diferencias educativas permanecieron en gran medida después de los análisis multivariantes: los graduados universitarios (razón de posibilidades [OR] = 0,37) eran menos propensos, en comparación con quienes tenían educación primaria, a manifestar la reforma importante que necesita su sistema de salud y eran más propensos (O = 2,57) a tener a un médico de cabecera. En Brasil, si bien las diferencias educativas se eliminaron en gran parte en los modelos con múltiples variables, las personas con cobertura privada manifestaron constantemente mejores resultados que aquellos con cobertura pública. En cambio, Colombia presentó la menor desigualdad a pesar de tener la desigualdad de ingresos más alta de los seis países. Conclusiones Se precisan investigaciones futuras para comprender las políticas y las estrategias que han llevado a que Colombia alcance niveles altos de equidad en la experiencia de atención de salud de pacientes, y a que Jamaica y Brasil presenten niveles altos de desigualdad.

RESUMO Objetivo Na América Latina e no Caribe, os países estão trabalhando para alcançar a cobertura universal de saúde e uma das prioridades é assegurar a equidade nestas nações. O objetivo deste estudo foi examinar a relação entre a situação socioeconômica e a experiência em atenção de saúde de adultos em seis países da ALC. Métodos Foi realizado um estudo transversal para examinar a relação entre aproveitamento escolar e sete desfechos da experiência em saúde em três áreas distintas: avaliação do sistema de saúde, acesso à assistência e experiência com o clínico geral. Foram usados dados de uma pesquisa do Banco Interamericano de Desenvolvimento realizada com adultos no Brasil, Colômbia, El Salvador, Jamaica, México e Panamá em 2012-2014. Resultados O Brasil e a Jamaica, os dois países com um sistema único de cobertura da rede pública de saúde, se destacaram por ter consideravelmente maior desigualdade segundo os resultados das análises bivariadas, sendo que os participantes com maior nível de instrução informaram experiências melhores em atenção de saúde em cinco dos sete desfechos. Na Jamaica, as diferenças relativas ao nível educacional permaneceram em grande parte nas análises multivariadas: em comparação aos indivíduos com nível primário de educação, os adultos com nível universitário (odds ratio [OR] 0,37) apontaram com menor frequência a necessidade de uma ampla reforma no sistema de saúde e indicaram com maior frequência (OR 2,57) ter um médico habitual. No Brasil, as diferenças relativas ao nível educacional foram na sua maior parte eliminadas nos modelos multivariados, apesar de os indivíduos com plano de saúde privado terem consistentemente informado melhores desfechos que os indivíduos atendidos na rede pública. Em contraste, o menor grau de desigualdade foi observado na Colômbia apesar de o país ter a maior desigualdade de renda dos seis países estudados. Conclusões Osutras pesquisas são necessárias para compreender as políticas e as estratégias responsáveis pelo alto grau de equidade na experiência em atenção de saúde dos pacientes na Colômbia e pelos altos níveis de desigualdade na Jamaica e no Brasil.

Understanding public perception of the need for major change in Latin American healthcare systems.

The opinions and experiences of the public regarding health services are valuable insights into identifying opportunities to improve healthcare systems. We analyzed the 2012-2013 Public Opinion Health Policy Survey carried out in Brazil (n = 1486), Colombia (n = 1485), El Salvador (n = 1460), Jamaica (n = 1480), México (n = 1492) and Panama (n = 1475). In these countries between 82 and 96% of participants perceived that their health systems needed fundamental changes. The most frequent barrier to access to healthcare was lack of the primary medical home, difficulties in obtaining medical care during the weekends and financial barriers. Type of health insurance and challenges in obtaining medical care during the weekends were associated with an increased opinion for the need for fundamental changes in healthcare systems, whereas having a primary medical home showed a protective effect. Focusing on tackling organizational and financial barriers and ensuring access to a primary medical home should be placed on the agenda of Latin American countries.

Gaps In Primary Care And Health System Performance In Six Latin American And Caribbean Countries.

The rapid demographic and epidemiological transitions occurring in Latin America and the Caribbean have led to high levels of noncommunicable diseases in the region. In addition to reduced risk factors for chronic conditions, a strong health system for managing chronic conditions is vital. This study assessed the extent to which populations in six Latin American and Caribbean countries receive high-quality primary care, and it examined the relationship between experiences with care and perceptions of health system performance. We applied a validated survey on access, use, and satisfaction with health care services to nationally representative samples of the populations of Brazil, Colombia, El Salvador, Jamaica, Mexico, and Panama. Respondents reported considerable gaps in the ways in which primary care is organized, financed, and delivered. Nearly half reported using the emergency department for a condition they considered treatable in a primary care setting. Reports of more primary care problems were associated with worse perceptions of health system performance and quality and less receipt of preventive care. Urgent attention to primary care performance is required as the region's population continues to age at an unprecedented rate.

Transforming Global Health by Improving the Science of Scale-Up.

In its report Global Health 2035, the Commission on Investing in Health proposed that health investments can reduce mortality in nearly all low- and middle-income countries to very low levels, thereby averting 10 million deaths per year from 2035 onward. Many of these gains could be achieved through scale-up of existing technologies and health services. A key instrument to close this gap is policy and implementation research (PIR) that aims to produce generalizable evidence on what works to implement successful interventions at scale. Rigorously designed PIR promotes global learning and local accountability. Much greater national and global investments in PIR capacity will be required to enable the scaling of effective approaches and to prevent the recycling of failed ideas. Sample questions for the PIR research agenda include how to close the gap in the delivery of essential services to the poor, which population interventions for non-communicable diseases are most applicable in different contexts, and how to engage non-state actors in equitable provision of health services in the context of universal health coverage.

Attributes of patient-centered primary care associated with the public perception of good healthcare quality in Brazil, Colombia, Mexico and El Salvador.

This study evaluated primary care attributes of patient-centered care associated with the public perception of good quality in Brazil, Colombia, Mexico and El Salvador. We conducted a secondary data analysis of a Latin American survey on public perceptions and experiences with healthcare systems. The primary care attributes examined were access, coordination, provider-patient communication, provision of health-related information and emotional support. A double-weighted multiple Poisson regression with robust variance model was performed. The study included between 1500 and 1503 adults in each country. The results identified four significant gaps in the provision of primary care: not all respondents had a regular place of care or a regular primary care doctor (Brazil 35.7%, Colombia 28.4%, Mexico 22% and El Salvador 45.4%). The communication with the primary care clinic was difficult (Brazil 44.2%, Colombia 41.3%, Mexico 45.1% and El Salvador 56.7%). There was a lack of coordination of care (Brazil 78.4%, Colombia 52.3%, Mexico 48% and El Salvador 55.9%). Also, there was a lack of information about healthy diet (Brazil 21.7%, Colombia 32.9%, Mexico 16.9% and El Salvador 20.8%). The public's perception of good quality was variable (Brazil 67%, Colombia 71.1%, Mexico 79.6% and El Salvador 79.5%). The primary care attributes associated with the perception of good quality were a primary care provider 'who knows relevant information about a patient's medical history', 'solves most of the health problems', 'spends enough time with the patient', 'coordinates healthcare' and a 'primary care clinic that is easy to communicate with'. In conclusion, the public has a positive perception of the quality of primary care, although it has unfulfilled expectations; further efforts are necessary to improve the provision of patient-centered primary care services in these four Latin American countries.

Population experiences of primary care in 11 Organization for Economic Cooperation and Development countries.

OBJECTIVE: To develop a measure of individual user assessments of primary care and test its association with health system performance and quality indicators. DESIGN: Cross-sectional analysis of secondary survey data collected in 2013. SETTING: Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK and the USA. STUDY PARTICIPANTS: 20 045 respondents. MAIN OUTCOME MEASURES: Individual report of financial protection (out of pocket expenses over USD 1000), lack of receipt of appropriate/timely care (use of the emergency room in the past 2 years, having consulted three of more doctors in the past year) and clinical prevention (blood pressure check in past year, cholesterol checked in the past 5 years, receipt of influenza vaccination in past year and report of any medical error). METHODS: A score of users' primary care experiences was constructed from 14 individual survey questions. Multivariable Poisson and augmented inverse-probability weighted regression assess the relationship between the primary care experience score and outcomes. RESULTS: Countries differed regarding the proportion of the population experiencing problems with primary care. In analyses controlling for age, sex, health status, chronic disease, income level and health insurance, users experiencing poorer primary care were significantly more likely to report significant out of pocket expenses, emergency room use in the past 2 years, having consulted more than three doctors in the past year, lower likelihood of blood pressure or cholesterol screening, an annual flu shot and higher reports of medical error. CONCLUSIONS: The measure of individual primary care experience can be used to differentiate among different country's primary care approaches and is strongly associated with overall health system performance and quality indicators.

The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010.

OBJECTIVES: I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. METHODS: I employed longitudinal ecological analysis using panel data from 4583 Brazilian municipalities from 1998 to 2010, totaling 54 253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. RESULTS: The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%. CONCLUSIONS: The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.

[The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998-2010]. / Efectos combinados de la ampliación de la atención primaria de salud y de las transferencias condicionadas de dinero en efectivo sobre la mortalidad infantil en Brasil, 1998-2010.

OBJECTIVES: I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. METHODS: I employed longitudinal ecological analysis using panel data from 4 583 Brazilian municipalities from 1998 to 2010, totaling 54 253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. RESULTS: The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%. CONCLUSIONS: The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.

Efectos combinados de la ampliación de la atención primaria de salud y de las transferencias condicionadas de dinero en efectivo sobre la mortalidad infantil en Brasil, 1998 - 2010 / The combined effects of the expansion of primary health care and conditional cash transfers on infant mortality in Brazil, 1998 - 2010

OBJETIVOS: Examiné los efectos combinados del acceso a la atención primaria mediante el Programa de Salud Familiar (PSF) y las transferencias condicionadas de dinero en efectivo del Programa Bolsa Familia (PBF) sobre la mortalidad infantil posneonatal (MIPN) en Brasil. MÉTODOS: Empleé un análisis ecológico longitudinal usando datos en panel de 4 583 municipios brasileños de 1998 al 2010, con 54 253 observaciones en total. Estimé modelos de regresión de efectos fijos por mínimos cuadrados ordinarios, con la tasa de MIPN como la variable dependiente y el PSF, el PBF y sus interacciones como las principales variables independientes de interés. RESULTADOS: La asociación de una mayor cobertura del PSF con una menor tasa de MIPN se volvió más fuerte conforme aumentaba la cobertura del PBF. En los promedios de todas las demás variables, cuando la cobertura de PBF era 25%, la MIPN predicha fue 5,24 (intervalo de confianza [IC] de 95% = 4,95, 5,53) para una cobertura del PSF de 0%, y de 3,54 (IC de 95% = 2,77, 4,31) para una cobertura del PSF de 100%. Cuando la cobertura del PBF era de 60%, la MIPN predicha fue 4,65 (IC de 95% = 4,36, 4,94) para una cobertura del PSF de 0%, y de 1,38 (IC de 95% = 0,88, 1,89) para una cobertura del PSF de 100%. CONCLUSIONES: El efecto del PSF depende de la ampliación del PBF. Para las poblaciones empobrecidas y subatendidas, la combinación de intervenciones tanto del lado de la oferta como del lado de la demanda podría ser necesaria para mejorar los resultados en salud.

OBJECTIVES: I examined the combined effects of access to primary care through the Family Health Program (FHP) and conditional cash transfers from the Bolsa Familia Program (BFP) on postneonatal infant mortality (PNIM) in Brazil. METHODS: I employed longitudinal ecological analysis using panel data from 4 583 Brazilian municipalities from 1998 to 2010, totaling 54 253 observations. I estimated fixed-effects ordinary least squares regressions models with PNIM rate as the dependent variable and FHP, BFP, and their interactions as the main independent variables of interest. RESULTS: The association of higher FHP coverage with lower PNIM became stronger as BFP coverage increased. At the means of all other variables, when BFP coverage was 25%, predicted PNIM was 5.24 (95% confidence interval [CI] = 4.95, 5.53) for FHP coverage = 0% and 3.54 (95% CI = 2.77, 4.31) for FHP coverage = 100%. When BFP coverage was 60%, predicted PNIM was 4.65 (95% CI = 4.36, 4.94) when FHP coverage = 0% and 1.38 (95% CI = 0.88, 1.89) when FHP coverage = 100%. CONCLUSIONS: The effect of the FHP depends on the expansion of the BFP. For impoverished, underserved populations, combining supply- and demand-side interventions may be necessary to improve health outcomes.